S T R A T E G I C CONTROL F O R A U.K. R E G I O N A L HVALTH A U T H O R I T Y
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A CONCEPTUAL FRAMEWORKM a r k F. C a n t l e y
N o v e m b e r 1 9 7 8
Research Memoranda are interim reports on research being conducted by the International Institute for Applied Systems Analysis, and as such receive only limited scientific review. Views or opinions contained herein do not necessarily represent those o f the Institute or o f the National Member Organizations supporting the Institute.
Copyright @ 1978 IIASA
AU rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopy, recording, or any information storage or retrieval system, without permission in writing from the publisher.
Preface
This paper forms the starting point for a research project by IIASA, in cooperation with one of the U.K. regional health authorities, into the development of procedures for monitoring and controlling the implementation of strategic plans. The main body of IIASA research into Health Care Systems is conducted
within the Human Settlements and Services Area; but the strategic planning processes are an example of the "Program Management"
activities which form one of the research tasks in the Management and Technology Area.
Abstract
After a brief review of the nature of strategic planning, and the problems of defining health service objectives, the paper concentrates on the question of "strategic control", in the context of a regional health authority. The purpose of monitoring is defined in detail. A critical review of concepts of control in various disciplines considers their suitability to the health authority context. An integration of feedforward and feedback control loops is developed, in order to meet the
specific characteristics of a system in which "environment" can be viewed as the "input", and to provide the adaptive, learning capability which is required by the situation of insufficient data, ignorance of underlying mechanisms, and continuing change.
Acknowledgements
As with most IIASA research, the ideas offered here arise from team-work and discussions. Thanks are especially due to Loretta Hervey, whose experience of health care and diligence in the library widened my horizons. To David Hughes, whose comments greatly improved an earlier draft. To Richard Gibbs, for
introducing me to the administrative history of the U.K. health scene, and to his colleagues. To the multi-national flow of visitors through my office, many of whom infected me with the germ of an idea. And to my permanent personal advisor on nursing care.
Finally, to those constructive critics who will point out the weaknesses and omissions, and thereby contribute valuably to the cybernetic process of feedback control.
C o n t e n t s
1 . INTRODUCTION
1 . 1 "Program Management" and H e a l t h C a r e
Page 1 1 1 . 2 P u r p o s e o f P a p e r : A C o n c e p t u a l S t a r t i n g - P o i n t 4 1 . 3 The " R e g i o n a l " C o n t e x t o f t h e R e s e a r c h 6
2. STRATEGIC PLANNING
2.1 On S t r a t e g i c P l a n n i n g i n G e n e r a l
2 . 2 S t r a t e g i c P l a n n i n g C o n c e p t s i n t h e H e a l t h S e r v i c e 9
3. OBJZCTIVZS AND TARGETS 13
4 . M O N I T O R I N G AND CONTROL: THE N E E D , THE METHODS,
THE SHORTCOMINGS
4.1 I n t r o d u c t i o n and D i s c u s s i o n o f Terms 4.2 The Need f o r M o n i t o r i n g : A D e f i n i t i o n
4.3 T h e o r i e s a n d Methods o f C o n t r o l : ~ n t r o d u c t i o n 4 . 4 O p t i m a l C o n t r o l T h e o r y , Economics and E c o l o g y 4.5 F i n a n c i a l C o n t r o l , The " C y b e r n e t i c " Model, and
i t s L i m i t a t i o n s
4.6 From " F e e d b a c k " t o " F e e d f o r w a r d " : E x t e n d i n g t h e C y b e r n e t i c Model
4 . 7 S h o r t c o m i n g s and P r o p o s a l s
5. ILLUSTRATIVE CASE
R e f e r e n c e s
S t r a t e g i c C o n t r o l f o r a U . K . R e g i o n a l H e a l t h A u t h o r i t y
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A C o n c e ~ t u a l Framework1 . I N T R O D U C T I O N
1 . 1 "Program Management" and H e a l t h C a r e
One o f t h e t o p i c s i d e n t i f i e d i n t h e 1978-79 R e s e a r c h P l a n [ I ] o f IIASA1s Management and Technology Area (PIMT) i s d e s c r i b e d as Program Management: "The g e n e r a l p r o b l e m o f
t r a n s l a t i n g i d e a l , m u l t i - d i m e n s i o n a l g o a l s i n t o a c h i e v a b l e g o d l s , a n d d e v i s i n g t h e n e c e s s a r y mechanisms f o r a c h i e v i n g t h i s i n a complex o r g a n i z a t i o n a l s i t u a t i o n . " An i m p o r t a n t c o n t e m p o r a r y p r o b l e m , which p r e c i s e l y f i t s t h i s d e s c r i p t i o n , i s t h a t o f h e a l t h care p l a n n i n g .
H e a l t h c a r e s y s t e m s a r e a l r e a d y t h e s u b j e c t o f work a t IIASA, f o r t h e t o p i c f a l l s s q u a r e l y w i t h i n t h e d e f i n i t i o n o f
" u n i v e r s a l problems" a s d e f i n e d i n IIASA1s R e s e a r c h P l a n [ I ] . E v i d e n c e o f t h i s u n i v e r s a l i t y i s p r o v i d e d by t h e w i d e s p r e a d d e b a t e s on t h e need f o r r e o r g a n i z a t i o n and improved p l a n n i n g o f e x i s t i n g h e a l t h s y s t e m s , which a r e c u r r e n t l y t a k i n g p l a c e i n many c o u n t r i e s o f t h e w o r l d . The e x a m p l e s q u o t e d b e l o w b o t h d e m o n s t r a t e t h i s , and i n t r o d u c e some o f t h e c e n t r a l i s s u e s .
From Canada, Evans [ 2 ] : "The s c e n e i s now c h a n g i n g w i t h new e f f o r t s t o o r g a n i z e r e g i o n a l and l o c a l h e a l t h s e r v i c e s on a c o m p r e h e n s i v e b a s i s . The d e s i r a b i l i t y o f r e g i o n a l o r d i s t r i c t c o n t r o l o f t h e p l a n n i n g and o p e r a t i o n o f h e a l t h s e r v i c e s h a s b e e n a c c e p t e d i n p r i n c i p l e i n a l l p r o v i n c e s of Canada, b u t
i n t e r m e d i a t e s t r u c t u r e s f o r a d m i n i s t e r i n g h e a l t h s e r v i c e s a t t h e r e g i o n a l l e v e l h a v e o n l y b e e n d e v e l o p e d i n Q u e b e c . "
From A u s t r a l i a , H e t z e l [ 3 ] r e p o r t s how a c h a n g e o f g o v e r n - ment " a t t h e end o f 1972 l e d t o t h e s e t t i n g u p o f a new N a t i o n a l H o s p i t a l s a n d H e a l t h S e r v i c e s Commission which i m m e d i a t e l y
p u r s u e d a n a c t i v e p o l i c y o f i n i t i a t i n g community h e a l t h c e n t e r d e v e l o p m e n t i n a l l s t a t e s , " t h o u g h l o c a l p o l i t i c a l c o n d i t i o n s a r e s a i d t o h a v e l e d t o s u b s e q u e n t m o d i f i c a t i o n s o f t h e o r i g i n a l p r o p o s a l s . T h i s c a v e a t i s e q u a l l y u n i v e r s a l , a s t h e f o l l o w i n g q u o t a t i o n from A l t e n s t e t t e r [ 4 ] s u g g e s t s :
" I n r e s p o n s e t o s k y r o c k e t i n g i n c r e a s e s i n t h e
p r o p o r t i o n o f GNP t h a t g o e s i n t o t h e h e a l t h care s e c t o r , most i n d u s t r i a l n a t i o n s a r e s e e k i n g a l t e r n a t i v e modes o f d e l i v e r i n g and f i n a n c i n g h e d l t h s e r v i c e s . The
F e d e r a l R e p u b l i c o f Germany i s no e x c e p t i o n . However, n o t a l l i n n o v a t i o n s and i n t e r v e n t i o n s , a d o p t e d r e c e n t l y , r e s p o n d t o b a s i c i m p e r a t i v e s o f a c l i e n t - o r i e n t e d
h e a l t h c a r e s y s t e m t h a t g u a r a n t e e s a v a i l a b i l i t y , a c c e s - s i b i l i t y , a c c e p t a b i l i t y , c o n t i n u i t y and q u a l i t y o f
h e a l t h care s e r v i c e s . I n s t e a d , s u c h i n t e r v e n t i o n s a n d
i n n o v a t i o n s t e n d t o r e s p o n d t o t h e r e q u i r e m e n t s of t h e p o l i t i c a l - a d m i n i s t r a t i v e s y s t e m . "
P e r h a p s b e s t known of a l l r e o r g a n i z a t i o n d e b a t e s i s t h e c o n t i n u i n g U.S. d i s c u s s i o n a n d n e g o t i a t i o n on t h e s u b j e c t .
A t k i s s o n and G r i m e s [ 5 ] ( s o u r c e o f t h e f o l l o w i n g two q u o t a t i o n s ) d e s c r i b e t h e N a t i o n a l H e a l t h P l a n n i n g and R e s o u r c e s Development A c t of 1974 ( P . L . 93-641) which P r e s i d e n t Ford s i g n e d i n t o l a w
i n J a n u a r y 1975. W h i l e t h i s l e a v e s open many o f t h e f i n a n c i n g q u e s t i o n s ( s t i l l b e i n g d e b a t e d by C o n g r e s s d u r i n g P r e s i d e n t
C a r t e r ' s a d m i n i s t r a t i o n
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e s p e c i a l l y t h e C o s t C o n t r o l P r o p o s a l ) , P.L. 93-641 b e a r s some s t r i k i n g s i m i l a r i t i e s t o t h e U . K . re- o r g a n i z a t i o n d e s c r i b e d below. "The a c t f a s h i o n s s e v e r a l new programs; p r o v i d e s f o r t h e e s t a b l i s h m e n t o f n a t i o n a l h e a l t h p l a n n i n g g u i d e l i n e s ; c r e a t e s a new s y s t e m o f h e a l t h s e r v i c e s p l a n n i n g and r e g u l a t o r y a g e n c i e s ; p r o v i d e s some of t h e ' f r o n te n d ' p r e p a r a t i o n f o r t h e a n t i c i p a t e d a d o p t i o n o f a n a t i o n a l h e a l t h i n s u r a n c e p r o p o s a l ; a n d t e r m i n a t e s [ v a r i o u s p r e v i o u s l y e x i s t i n g ] p r o g r a m s . " Again l i k e t h e U . K . , t h e new H e a l t h S y s t e m s A g e n c i e s (HSAs) ( r e s p o n s i b l e f o r p o p u l a t i o n s o f 500,000 t o 3 m i l l i o n ) a r e
" r e q u i r e d t o d e v e l o p l o n g r a n g e h e a l t h p l a n s f o r t h e i r communi- t i e s a s w e l l a s a n n u a l i m p l e m e n t a t i o n p l a n s t o c a r r y o u t
i n c r e m e n t a l p o r t i o n s o f t h e l o n g r a n g e p l a n s . " Thus t h e U.S.
government, l i k e s o many o t h e r s , i s g r o p i n g t o w a r d s , and h a s i n p r i n c i p l e a c c e p t e d , a r e g u l a t o r y s t r a t e g y i n h e a l t h . The p r o c e s s
i s d e l a y e d by t h e p o l i t i c a l n e e d s f o r compromise, a s p o i n t e d o u t i n t h e A l t e n s t e t t e r q u o t a t i o n a b o v e . I n t h e U.S., Altman [ 6 ] h a s d e s c r i b e d t h e e v o l u t i o n o f t h e s y s t e m s e t up by P.L. 93-641, a n d t h e s t r u g g l e o f t h e s t a t e s t o r e t a i n c o n t r o l o f t h e HSAs.
W e c o n c l u d e s : " I n s h o r t , t h e c o n t r o l l i n g f a c t o r s i n h e a l t h
p l a n n i n g a r e p o l i t i c a l , n o t t e c h n i c a l , and t h e s e a r e o c c u r r i n g more a t t h e s t a t e a n d l o c a l l e v e l s t h a n many had p r e d i c t e d . "
The U . K . , which f o r m s t h e c o n t e x t f o r t h e r e s e a r c h d e s c r i b e d below, d i f f e r s from t h e f o u r c o u n t r i e s named above i n n o t h a v i n g a f e d e r a l s y s t e m . The f o r m a l i m p l e m e n t a t i o n o f t h e 1974 r e o r g a - n i z a t i o n w a s t h e r e f o r e more s t r a i g h t f o r w a r d , a l t h o u g h a s w i l l b e s e e n below, some o f t h e b e n e f i t s o f f e d e r a l i s m a r e s o u g h t i n t h e d e l e g a t i o n t o R e g i o n a l H e a l t h A u t h o r i t i e s o f c o n s i d e r a b l e f r e e - dom t o d e f i n e t h e i r own o b j e c t i v e s .
The U . K . ' s r e l a t i v e l y weak economic p e r f o r m a n c e i n r e c e n t y e a r s h a s a t l e a s t t h e a d v a n t a g e o f s h a r p e n i n g i t s i n t e r e s t i n c o s t c o n t r o l , t h u s f u r t h e r r e n d e r i n g i t s h e a l t h s y s t e m o f
i n t e r e s t t o a w i d e r a u d i e n c e . B u t a t t h e same t i m e , t h e e m p h a s i s o n b u d g e t a r y s t r i n g e n c y l i n k e d w i t h t h e i m p l e m e n t a t i o n o f more s y s t e m a t i c a l l y d e s i g n e d p l a n n i n g s t r u c t u r e s f o c u s e s a t t e n t i o n o n t h e n e e d t o p u r s u e e v e r more s c i e n t i f i c a l l y t h e maximum e f f e c - t i v e n e s s i n t h e u s e o f r e s o u r c e s .
An i m p a s s i o n e d p l e a , b o t h e m p h a s i z i n g t h e need and o f f e r i n g some of t h e means t o meet i t , was made a t a c o n f e r e n c e i n
Maryland, U.S.A., o r g a n i z e d by t h e I n t e r n a t i o n a l E p i d e m i o l o g i c a l
A s s o c i a t i o n i n 1975 ( s p o n s o r e d by t h e H e a l t h R e s o u r c e s Adminis- t r a t i o n o f t h e U.S. D e p a r t m e n t o f H e a l t h , E d u c a t i o n a n d W e l f a r e ) . T h e i r " C o n f e r e n c e S t a t e m e n t " [ 7 ] s t a r t s a s f o l l o w s :
" 1 . U n t i l v e r y r e c e n t l y i n t h e U n i t e d S t a t e s t h e r e h a v e b e e n few c o n s t r a i n t s on h e a l t h c a r e r e s o u r c e s , n o e f f e c t i v e p l a n n i n g p r o c e s s e s t h a t r e l a t e t h e f l o w o f f u n d s f o r manpower and c a p i t a l t o community n e e d s , a n d no c l e a r f o c i o f r e s p o n s i b i l i t y and a c c o u n t a b i l i t y . T h e r e f o r e , t h e r e h a s b e e n no o b v i o u s n e e d a n d l i t t l e i n c e n t i v e f o r t h e p r a c t i c a l a p p l i c a t i o n o f e p i d e m i o l o - g i c a l s k i l l s a n d f o r t h e d e v e l o p m e n t o f a d e q u a t e h e a l t h s e r v i c e s management p e r s o n n e l and h e a l t h i n f o r m a t i o n s y s t e m s .
2. The r e c e n t f e d e r a l PSRO [ P r o f e s s i o n a l S t a n d a r d s Review O r g a n i z a t i o n ] l e g i s l a t i o n , t h e H e a l t h S e r v i c e s R e s e a r c h , H e a l t h S t a t i s t i c s a n d M e d i c a l L i b r a r i e s A c t , a n d t h e H e a l t h P l a n n i n g a n d R e s o u r c e s Development A c t h a v e d r a m a t i c a l l y c h a n g e d t h i s s i t u a t i o n . Each new PSRO, H e a l t h S y s t e m s Agency, and S t a t e H e a l t h Develop- ment A u t h o r i t y now b e i n g e s t a b l i s h e d w i l l r e q u i r e p e r s o n n e l w i t h e p i d e m i o l o g i c a l a n d management s k i l l s a s w e l l a s c l i n i c a l e x p e r i e n c e , a n d a m u t u a l u n d e r - s t a n d i n g o f t h e i n t e r r e l a t i o n s h i p s b e t w e e n t h e s e s k i l l s .
3 . The d i s c i p l i n e o f e p i d e m i o l o g y , t o g e t h e r w i t h t h e a p p l i e d f i e l d s o f e c o n o m i c s , management s c i e n c e s , and t h e s o c i a l s c i e n c e s , p r o v i d e t h e e s s e n t i a l q u a n t i t a t i v e a n d a n a l y t i c a l m e t h o d s , p r i n c i p l e s o f l o g i c a l i n q u i r y , a n d r u l e s f o r e v i d e n c e f o r :
i n v e s t i g a t i n g t h e n a t u r a l h i s t o r y o f d i s e a s e ; d i a g n o s i n g , m e a s u r i n g a n d p r o j e c t i n g t h e h e a l t h n e e d s o f c o m m u n i t i e s and p o p u l a t i o n s ;
d e t e r m i n i n g h e a l t h g o a l s , o b j e c t i v e s a n d p r i o r i t i e s ; a l l o c a t i n g a n d managing h e a l t h c a r e r e s o u r c e s ;
a s s e s s i n g i n t e r v e n t i o n s t r a t e g i e s and e v a l u a t i n g t h e i m p a c t o f h e a l t h s e r v i c e s . "
The s t a t e m e n t c o n t i n u e s , e m p h a s i z i n g t h e r e q u i r e m e n t f o r e p i d e m i o l o g i c a l p e r s o n n e l . B u t t h e r e f e r e n c e t o " t h e a p p l i e d f i e l d s o f e c o n o m i c s , management s c i e n c e s and t h e s o c i a l
s c i e n c e s " i n d i c a t e s why t h e r e e x i s t s a n i m p o r t a n t r o l e f o r o r g a n i z a t i o n s and i n d i v i d u a l s i n a p p l i e d s y s t e m s a n a l y s i s t o r e c o g n i z e t h e need a n d t h e p o t e n t i a l f o r t h e i r t a l e n t s i n h e a l t h c a r e s y s t e m p l a n n i n g . A l t e n s t e t t e r [ 4 ] makes a s i m i l a r p o i n t , r e f e r r i n g t o
"...
two a r e a s i n h e a l t h s e r v i c e s r e s e a r c h i n w h i c h t h e t h e o r e t i c a l and e m p i r i c a l s t a t e o f knowledge, p a r t i c u - l a r l y i n Germany, i s r a t h e r l i m i t e d . A t p r e s e n t , t h e r e i s l i t t l e c a p a b i l i t y t h a t c o u l d r i g o r o u s l y assess t h e e f f e c t s o f p a s t n a t i o n a l i n n o v a t i o n s , c o n t r o l , a n dsteering instruments, on health services organizations in different regions and communities in the Federal Republic of Germany. Similarly, the capability of forecasting potential effects of new interventions is quite limited. Evaluations tend to be made in hind- sight. Causal explanations are based on intuitive observation, questionable perceptions and, often, limited analyses and ad hoc experiments, rather than on the basis of vigorous evaluations. Preferred solutions tend to influence such assessments, irres- pective of actual developments. "
Seeking a definition of "health services research," or of "orga- nizabional research in health services," she quotes Lewis [8]:
"Health services research can be viewed as the epidemiology of the health care system, when this system is conceived in its broadest terms. Put another way, HSR is evaluative research which may examine all or any part of the health care system,"
and Georgopoulos [9] :
"Better understanding and adequate knowledge of
organization at all levels of the system may hold the key to effective approaches and successful solutions.
Knowledge from the social, behavioral, and management sciences, in particular, could well prove crucial in this respect and infinitely more important than know- ledge from the health sciences themselves."
The strong statement by Georgopoulos is a suitable note on which to end this introduction. The widespread need and interest have been illustrated, and the invitation to the
management sciences is clear. The opportunity offered to IIASA by the cooperation of a Regional Health Authority in the United Kingdom is therefore timely. The help and farsightedness shown by the staff of the U.K. Department of Health and Social
Security's Operational Research Section, who encouraged our interest in the monitoring and control problems, is hereby acknowledged.
1.2 Purpose of Paper: A Conceptual Starting-Point
In the U.K. National Health Service (NHS), as in many organizations, there has been an increasing recognition of the need to expand both the time-scale and the scope of their formal planning activities. The service itself underwent a major
reorganization in 1974, centering on a shift from an "institu- tional" emphasis (as in the old Regional Hospital Boards), to a "total community health" emphasis, with its correspondingly broader implications. In 1976, the issue of a new "planning manual"
[lo]
by the U.K. government's Department of Health andS o c i a l S e c u r i t y (DHSS) i n c l u d e d a r e q u i r e m e n t f o r t h e p r e p a r a - t i o n o f 1 0 - y e a r " S t r a t e g i c P l a n s " by t h e s t i l l - r e c e n t l y - f o r m e d h e a l t h a u t h o r i t i e s . Work on t h e s e i s a l r e a d y w e l l a d v a n c e d , w i t h t h e f i r s t c y c l e o f p l a n s a p p e a r i n g e a r l y i n 1977, and r e v i s e d v e r s i o n s now i n p r e p a r a t i o n .
The NI3S manual d e f i n e s s t r a t e g i c p l a n n i n g a s " t h e means by which NHS a u t h o r i t i e s d e t e r m i n e t h e i r l o n g - r a n g e o b j e c t i v e s and p r i o r i t i e s f o r t h e d e v e l o p m e n t o f t h e f u l l r a n g e o f h e a l t h
s e r v i c e s , " a n d d e s c r i b e s b o t h s t r a t e g i c a n d o p e r a t i o n a l p l a n n i n g a s c o m p r i s i n g f i v e s t e p s :
' l a . T a k i n g s t o c k . Examining where t h e o r g a n i z a t i o n i s now, and f o r e c a s t i n g where i t i s l i k e l y t o f i n d i t s e l f a t t h e end o f t h e p l a n n i n g p e r i o d i f n o t h i n g i s done t o c h a n g e c o u r s e . T h i s w i l l r e q u i r e d i s c u s s i o n of c u r r e n t s e r v i c e s , r e s o u r c e s and t h e i r u s e r and
e x i s t i n g c o n s t r a i n t s on o p e r a t i o n .
b. O b j e c t i v e - s e t t i n g . Reviewing what t h e o r g a n i z a t i o n w i l l s e e k t o a c h i e v e i n t h e t i m e s p a n b e i n g c o n s i d e r e d
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i . e . , i t s a i m s o r o b j e c t i v e s . T h i s w i l l r e q u i r e c o n s i d e r a t i o n o f n e e d s , demands, a n d r e s o u r c e s . I t s h o u l d t a k e i n t o a c c o u n t t h e v a l u e s o f a l l c o n c e r n e d a s w e l l a s t h e g e n e r a l s o c i a l , economic and p o l i t i c a l c l i m a t e .
c. D e f i n i n g s t r a t e g y , D e c i d i n g how t o move t h e o r g a n i - z a t i o n from where i t i s now t o i t s a g r e e d o b j e c t i v e s . T h i s r e q u i r e s c o n s i d e r i n g a l t e r n a t i v e r o u t e s t o t h e g o a l s , t h e c o s t s a n d o t h e r i m p l i c a t i o n s ( q u a n t i t a t i v e and q u a l i t a t i v e ) o f e a c h , a n d t h e o r g a n i z a t i o n ' s
a b i l i t y t o manage e a c h r o u t i n g . A s e l e c t i o n b e t w e e n t h e o p t i o n s i s t h e n made, l e a d i n g t o t h e d e f i n i t i o n o f a n o v e r a l l s t r a t e g y o r programme.
d . D e v e l o p i n g a d e t a i l e d p l a n . D e c i d i n g how t h i s g e n e r a l s t r a t e g y o r programme i s t o b e i m p l e m e n t e d . T h i s means w o r k i n g o u t f i n a n c i a l , s t a f f i n g a n d o t h e r i m p l i c a t i o n s and p r e p a r i n g a f o r m a l p l a n f o r t h e p e r i o d i n v o l v e d .
e . M o n i t o r i n g i m p l e m e n t a t i o n . A s s e s s i n g d u r i n g and a f t e r i m p l e m e n t a t i o n , w h e t h e r t h e p l a n i s s t i l l r e l e v a n t t o t h e o b j e c t i v e s , and w h e t h e r p e r f o r n a n c e i s i n l i n e w i t h t h e p l a n . T h i s r e q u i r e s some means o f monitoring processes and evaluating r e s u l t s
.
" (Our i t a l i c s.
)The f i n a l p h r a s e o f t h e q u o t a t i o n i s i t a l i c i z e d , b e c a u s e a f t e r d i s c u s s i o n s i n IIASA and w i t h DHSS s t a f f , i t was f e l t t h a t t h e a r e a i n g r e a t e s t n e e d o f d e v e l o p m e n t l a y n o t i n t h e p r e p a r a - t i o n a n d p u b l i c a t i o n o f s t r a t e g i c p l a n s , s o much a s i n t h e
p r o c e s s e s o f m o n i t o r i n g , e v a l u a t i o n and c o n t r o l w h i c h s h o u l d f o l l o w them, accompany t h e i r i m p l e m e n t a t i o n , a n d l e a d t o t h e i r improvement. T h i s p a p e r d e s c r i b e s t h e c o n c e p t u a l framework
which h a s b e e n d e v e l o p e d a t IIASA a s a s t a r t i n g p o i n t f o r t h e work i n t h e f i e l d . The c o n c e p t o f m o n i t o r i n g and c o n t r o l h a s h a d r e l a t i v e l y l i t t l e p r o m i n e n c e i n t h e l i t e r a t u r e o f s t r a t e g i c p l a n n i n g . Some e f f o r t h a s t h e r e f o r e b e e n expended i n a s s e s s i n g t h e r e l e v a n c e o f p u b l i s h e d s t r a t e g i c p l a n n i n g l i t e r a t u r e a n d c o n t r a 1 t h e o r y c o n c e p t s t o t h e j o b i n h a n d , and i n c r e a t i n g f r o m t h e s e a c l e a r e r c o n c e p t of " S t r a t e g i c C o n t r o l " s u i t a b l e f o r a p u b l i c h e a l t h a u t h o r i t y .
1 . 3 The " R e g i o n a l " C a n t e x t o f t h e R e s e a r c h
The 1974 r e o r g a n i z a t i o n c r e a t e d 1 5 R e g i o n a l H e a l t h A u t h o r i t i e s i n England a n d Wales, e a c h t y p i c a l l y c o v e r i n g some 3 m i l l i o n
p e o p l e . C o - e x t e n s i v e w i t h t h e l o c a l g o v e r n m e n t " c o u n t i e s "
w i t h i n e a c h r e g i o n a r e i t s c o n s t i t u e n t " A r e a " H e a l t h A u t h o r i t i e s
-
t y p i c a l l y t h r e e o r f o u r ; and f o r management p u r p o s e s t h e s e a r e u s u a l l y s u b - d i v i d e d i n t o " D i s t r i c t s " o f some 200,000 p e o p l e . T h i s i s r e c k o n e d a n a p p r o p r i a t e c a t c h m e n t p o p u l a t i o n f o r a
" D i s t r i c t G e n e r a l H o s p i t a l " p r o v i d i n g a l l t h e b a s i c s p e c i a l i t i e s (if o n e s t a r t e d w i t h a " g r e e n f i e l d " s i t u a t i o n ) .
The r e l a t i o n s h i p o f t h e RHA t o t h e DHSS i s i m p o r t a n t , b u t i s n o t t h e s u b j e c t o f t h e r e s e a r c h . The DHSS a l l o c a t e s c e n t r a l government f u n d s b e t w e e n t h e r e g i o n s , and t h i s i s t h e i r s o l e f i n a n c i a l s u p p o r t . The r e g i o n s d o n o t h a v e b o r r o w i n g p o w e r s ,
n o r h o l d s i g n i f i c a n t f i n a n c i a l r e s e r v e s . The DHSS h a s a l s o i s s u e d a s e r i e s o f " g u i d e l i n e s " which m i g h t b e s e e n as s e t t i n g " s t r a t e g i c o b j e c t i v e s " f o r t h e r e g i o n s
-
as i n t h e " C o n s u l t a t i v e Document1'[ I 11 (March 1976)
,
"The Way Forward" [ I 21 ( S e p t e m b e r 1977),
andt h e " P l a n n i n g Guide-Linestt [ 1 3 ] (March 1 9 7 8 ) . The RHA m i g h t t h e r e f o r e a p p e a r t o be m e r e l y a " p o s t - b o x , " t r a n s m i t t i n g a n d t r a n s l a t i n g t h e c e n t r a l l y f o r m u l a t e d f i n a n c i a l c o n s t r a i n t s and p o l i c y o b j e c t i v e s t o i t s c o n s t i t u e n t a r e a s and d i s t r i c t s , and r e t u r n i n g t h e i r comments o n f e a s i b i l i t y a n d t h e i r l o c a l views t o t h e DHSS. Such a v i e w i s c l e a r l y a n d e x p l i c i t l y r e b u t t e d , however, i n t h e DHSS documents r e f e r r e d t o . F o r i n s t a n c e , i n t h e , l a t e s t , P l a n n i n g Guide-Lines [ 1 3 ] :
" P r o j e c t i o n s a r e g i v e n i n P a r t 4 i l l u s t r a t i n g a p o s s i - b l e n a t i o n a l d i s t r i b u t i o n o f e x p e n d i t u r e a n d l e v e l o f
s e r v i c e p r o v i s i o n i n 1981/82 c o n s i s t e n t w i t h t h e s e f i n a n c i a l a s s u m p t i o n s and c o m p a t i b l e w i t h M i n i s t e r s ' p r i o r i t i e s . T h e s e i l l u s t r a t i v e p r o j e c t i o n s a r e n o t
t a r g e t s , b u t s i g n p o s t s i n d i c a t i n g t h e d i r e c t i o n o f c h a n g e t o be p u r s u e d t h r o u g h t h e s t r a t e g i c p l a n n i n g d e c a d e .
They a r e n o t s p e c i f i c t a r g e t s f o r n a t i o n a l d e v e l o p m e n t s , s t i l l l e s s l o c a l t a r g e t s t o b e aimed a t by p a r t i c u l a r a u t h o r i t i e s r e g a r d l e s s of l o c a l c i r c u m s t a n c e s or o f t h e b a s e l i n e s f r o m w h i c h t h e y s t a r t . The p r o j e c t i o n s
i l l u s t r a t e n a t i o n a l a v e r a g e s which may r e f l e c t w i d e l o c a l v a r i a t i o n s i n p a t t e r n s o f e x p e n d i t u r e a n d p r o v i s i o n o f s e r v i c e s . "
T h i s q u o t a t i o n
-
a n d many o t h e r p u b l i s h e d a n d p r i v a t e s t a t e m e n t s b y DHSS o f f i c i a l s a n d m i n i s t e r s-
make it c l e a r t h a t t h e RHA h a s a s i g n i f i c a n t r o l e t o p l a y i n t h e f o r m u l a t i o n o f i t s own r e g i o n ' s o b j e c t i v e s a n d s t r a t e g y , a n d i n m o n i t o r i n g i m p l e m e n t a t i o n ( i . e . , t h e l i s t o f a c t i v i t i e s q u o t e d i n 1 . 2 a b o v e ) . I t i s o n t h i s p r o - cess o f s t r a t e g y f o r m u l a t i o n w i t h i n t h e R e g i o n , a n d m o r e p a r t i c - u l a r l y , o n t h e m o n i t o r i n g a t r e g i o n a l l e v e l o f t h e i m p l e m e n t a t i o n o f t h i s s t r a t e q y , t h a t t h e r e s e a r c h i s c o n c e n t r a t i n s . T h ed i a g r a m i n ~ i ~ ; ; e 1 i l l u s t r a t e s t h e f o r m a l r e l a t i o n s h i p s , a n d i s t a k e n f r o m t h e NHS P l a n n i n g Manual [ l o ] .
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DHSS REVIEWS REGIONAL PLANS ;
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F i g u r e 1 THE FLOW OF GUIDELINES PLANS I N THE N.H.S.
2. STRATEGIC PTANNING
2.1 On S t r a t e s i c P l a n n i n s i n G e n e r a l
An e x t e n s i v e l i t e r a t u r e h a s d e v e l o p e d o v e r t h e l a s t 20 y e a r s o r s o i n t h e f i e l d o r f i e l d s v a r i o u s l y d e s c r i b e d a s " s t r a t e g i c , "
" l o n g - r a n g e , " o r " c o r p o r a t e " p l a n n i n g . A l t h o u g h t h e r e a r e some d i f f e r e n c e s o f t e r m i n o l o g y between t h e v a r i o u s a u t h o r s , t h e r e i s a f a i r l y h i g h d e g r e e o f c o n s e n s u s on t h e main f e a t u r e s . Drucker
[ 1 4 ] , i n a p a p e r on l o n g - r a n g e p l a n n i n g p u b l i s h e d n e a r l y 2 0 y e a r s a g o , d e f i n e d it a s f o l l o w s :
"
. . .
t h e c o n t i n u o u s : p r o c e s s o f making present entrepreneurial(risk taking) decisions s y s t e n a t i c a l l y and w i t h t h e b e s t p o s s i b l e knowledge o f t h e i r f u t u r i t y , o r g a n i z i n g system- a t i c a l l y the efforts. needed t o c a r r y o u t t h e s e d e c i s i o n s , and m e a s u r i n g t h e r e s u l t s o f t h e s e d e c i s i o n s a g a i n s t t h e e x p e c t a t i o n s t h r o u g h organized, systematic feed-back
. "
S t e i n e r [ I S ] and o t h e r s p u b l i s h e d many case s t u d i e s o f how o r g a n i z a t i o n s c o n d u c t e d t h e i r s t r a t e g i c p l a n n i n g , a n d how t h e i r p l a n n i n g methods had b e e n c h a n g i n g i n r e c e n t y e a r s
-
g e n e r a l l y i n t h e d i r e c t i o n o f l o n g e r t i m e - s p a n s and g r e a t e r f o r m a l i t y o f p r o c e d u r e . The j o u r n a l "Long Range P l a n n i n g " [ I 61 was s t a r t e di n 1968 by t h e U . K . Long Range P l a n n i n g S o c i e t y , and c i r c u l a t i o n a n d membership h a v e grown r a p i d l y . A m a j o r a t t e m p t t o d i s t i l a f o r m a l , " a n a l y t i c " a p p r o a c h t o c o r p o r a t e s t r a t e g i c p l a n n i n g was p u b l i s h e d by Ansoff [ I 7 1 i n 1965, a n d h i s " C o r p o r a t e S t r a t e g y "
h a s a c h i e v e d w i d e s p r e a d i n f l u e n c e : it i s f u r t h e r d e s c r i b e d below.
A u t h o r s s u c h a s B e e r [1 81 a n d Ozbekhan [ I 91 p l a c e d g r e a t e r e m p h a s i s o n t h e t h e o r e t i c a l a s p e c t s o f p l a n n i n g a n d c o n t r o l s y s t e m s , a s d i d Ackoff 1201; b u t i n a l l c a s e s w i t h a n e m p h a s i s l e s s on t h e o r y t h a n o n p r a c t i c a l a p p l i c a t i o n i n d e s i g n i n g
e f f e c t i v e " s y s t e m s . "
The a u t h o r s a b o v e a r e a few of t h e m a j o r names a s s o c i a t e d w i t h t h e t h e o r y a n d p r a c t i c e o f s t r a t e g i c p l a n n i n g , i n E n g l i s h -
l a n g u a g e p u b l i c a t i o n s . Many o f t h e p a p e r s a r e w r i t t e n i n terms o f p r o f i t - s e e k i n g o r g a n i z a t i o n s o p e r a t i n g i n m a r k e t e c o n o m i e s ; b u t i t was r e c o g n i z e d t h a t many o f t h e n e e d s g i v i n g r i s e t o l o n g e r - t e r m a n d more s t r a t e g i c p l a n n i n g , and many o f t h e t e c h - n i q u e s t o m e e t t h e s e n e e d s , w e r e no less a p p l i c a b l e t o p u b l i c s e r v i c e a c t i v i t i e s . Formal 5-year p l a n s f o r a l l s e c t o r s o f t h e n a t i o n a l economy h a v e l o n g b e e n f a m i l i a r i n s o c i a l i s t c o u n t r i e s . I n t h e m a r k e t e c o n o m i e s , t h e p r o p e r s c o p e o f c e n t r a l government r e g u l a t i o n , and t h e f u n c t i o n s f o r which i t s h o u l d a c c e p t r e s p o n - s i b i l i t y , h a v e l o n g b e e n t h e s u b j e c t o f d e b a t e . T h e r e h a s c l e a r l y b e e n a g r a d u a l a n d g e o g r a p h i c a l l y w i d e s p r e a d a c c e p t a n c e o f t h e n e e d f o r i t s r o l e t o i n c r e a s e . I n t h e f i e l d of economic manage- m e n t , t h e r o l e h a s expanded from a g g r e g a t e f i n a n c i a l management
t o w a r d s more s e l e c t i v e i n t e r v e n t i o n , and " i n d i c a t i v e , " s e c t o r a l , l o n g e r - t e r m p l a n n i n g . T h i s was p a r a l l e l e d by c o r r e s p o n d i n g
p l a n n i n g f o r t h e p u b l i c l y f i n a n c e d s e r v i c e s s u c h a s d e f e n c e , e d u c a t i o n and h e a l t h . The t h i n k i n g i n 1970 i s e p i t o m i z e d by t h e f o l l o w i n g q u o t a t i o n from a n OECD p a p e r on e c o n o n i c g r o w t h [ 2 1 ] :
" 1 . Such o b j e c t i v e s a s t h e a l l e v i a t i o n o f p o v e r t y , m e e t i n g t h e demands a n d a s p i r a t i o n s f o r e d u c a t i o n a l o p p o r t u n i t i e s and a d e q u a t e h e a l t h and s o c i a l s e c u r i t y p r o v i s i o n s , t h e p r e v e n t i o n of t h e p o l l u t i o n o f t h e e n v i r o n m e n t , u r b a n c o n g e s t i o n and d e c a y , and l o s s o f a m e n i t y , a n d t h e i m p l i c a t i o n s f o r l a n d u s e c r e a t e o b v i o u s and i m p o r t a n t p r o b l e m s o f r e s o u r c e a l l o c a t i o n .
2. I f governments a r e t o d e v i s e e f f e c t i v e programmes o f a c t i o n i n t h e s e f i e l d s , t h e y w i l l need t o f r a m e s u c h p o l i c i e s and p l a n t h e i r i m p l e n e n t a t i o n o n a
l o n g - t e r m b a s i s : t h e r e l e v a n t t i m e h o r i z o n w i l l o f t e n b e much l o n g e r t h a n t h a t i m p l i c i t i n c o n v e n t i o n a l
f i v e - y e a r p l a n s and p r o j e c t i o n s . "
The r e o r g a n i z a t i o n o f t h e U . K . N a t i o n a l H e a l t h S e r v i c e i n 1974, t h e r e d e f i n i t i o n o f i t s o b j e c t i v e s , and t h e s u b s e q u e n t e m p h a s i s on 10-year p l a n s a l l f o l l o w n a t u r a l l y f r o m t h e above h i s t o r i c a l e v o l u t i o n o f v i e w s o n s t r a t e g i c p l a n n i n g . I n t h e
f o l l o w i n g s e c t i o n , w e c o n s i d e r more s p e c i f i c a l l y t h e a p p l i c a t i o n o f some o f t h e p u b l i s h e d p l a n n i n g c o n c e p t s t o a r e g i o n a l h e a l t h a u t h o r i t y ; and i n s e c t i o n 4 t h e q u e s t i o n o f s t r a t e g i c m o n i t o r i n g and c o n t r o l .
2.2 S t r a t e g i c P l a n n i n g C o n c e p t s i n t h e H e a l t h S e r v i c e
F i g u r e 2 i s a v e r y summary p i c t u r e o f a s t r a t e g i c p l a n n i n g p r o c e s s . I t c o r r e s p o n d s t o A n s o f f ' s " a n a l y t i c a p p r o a c h , " b u t a t t h i s l e v e l o f a b s t r a c t i o n would be common t o many a u t h o r s . I t s h o u l d b e s t r e s s e d t h a t t h i s d i a g r a m r e p r e s e n t s o n l y t h e p l a n f o r m u l a t i o n p r o c e s s : i t d o e s n o t e x p l i c i t l y i n c l u d e t h e c o n t r o l o f i m p l e m e n t a t i o n , and c o u l d t h u s r e a d i l y l e a d t o t h e g e n e r a t i o n o f an- i n f e a s i b l e p l a n . The o n l y safegua;d a g a i n s t t h i s l i e s i n t h e r e a l i s m and a c c u r a c y of t h e f o r e c a s t of e n v i r o n m e n t a l f a c t o r s , a n d o f t h e a s s u m p t i o n s u s e d i n f o r e c a s t i n g what p e r f o r m a n c e w i l l r e s u l t from t h e i n t e r a c t i o n between t h e p l a n and t h i s e n v i r o n m e n t . The o b j e c t i v e s may c o m p r i s e a few o r many, q u a n t i t a t i v e and q u a l i - t a t i v e ; b u t i n w h a t e v e r fa-?n t h e y a r e e x p r e s s e d , t h e f o r e c a s t h a s t o b e p r e p a r e d i n t h e same t e r n s , s o t h a t c o m p a r i s o n c a n b e made.
From t h e c o m p a r i s o n , o r " g a p a n a l y s i s , " f o l l o w s e i t h e r r e v i s i o n o f t h e o b j e c t i v e s , o r o f t h e c u r r e n t p l a n , o r b o t h ; u n t i l
a p p a r e n t c o n s i s t e n c y i s a c h i e v e d .
T h i s a p p r o a c h c a n r e a d i l y b e t r a n s l a t e d i n p r i n c i p l e i n t o t h e c o n t e x t of a h e a l t h c a r e s y s t e n f o r a p a r t i c u l a r community.
Such a t r a n s l a t i o n i s r e p r e s e n t e d by F i g u r e 3 , which i s a s l i g h t l y f u l l e r c o n c e p t u a l p i c t u r e o f t h e p r o c e s s o f p l a n f o r m u l a t i o n .
A d i s t i n c t i o n i s drawn between t h e g e n e r a l , l o n g - t e r m "norms"
o r " v a l u e s , " and t h e s p e c i f i c , s c h e d u l e d g o a l s by which t h e y a r e
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to be pursued during the next planning period. The "Environment,"
by definition outside the control of the authority, is summarized in terms of economic, demographic, morbidity and technological prospects and probable changes. A distinction is drawn between
"resources and capabilities" (i-e., mainly the existing staff, buildings and equipment) and the "operating policies"
-
how theresources are used. The resources will be influenced in the long term primarily through the capital expenditure programe, through closure and redeployment of facilities, and through the decisions on staff recruitment and training. The operating policies will be constrained by the staff, buildings and equipment, and by the revenue budget. Clearly the whole system is closely connected;
between buildings, staff, client needs and operating policies;
between capital program and revenue implTcations; and between successive time periods.
National guide-lines; long-term public expectations;
.
General ideals about # 4- quality of life and e eH society, and the role (& of health scheduled / # '\ P 0 # f / Measurable, scheduled.
\ 1 Present and targets for specific , Comparison : 11
forecast sectors of activity, 1 I environment: by geographical area to identify I /.
Economic (Revenue & infeasibility or // Capital Budgets); unacceptability<,
b on current plans, \ \ Demographic; Morbidity; resources, \\ Forecast Technological (Medical future Science) ; ther social and the authority's Plans for expanding, Currently planned contracting, redeploying, future operating modifying resources 0 rC # h-..Ir Figure 3 "GAP ANALYSIS" APPLIED TO STRATEGY FOFQIULATION IN HEALTH CARE3. 'OBJECTIVES AND TARGETS
Nothing has yet been said about the objectives and targets, which figure prominently in the strategic plan formulation pro- cess outlined above. A huge literature exists on the subject of the measurement of a society's health, via health indicators or indexes; and on the measurement of the output and efficiency of hospitals, doctors, and other resources for health care. For
example, a classic paper by Fanshel and Bush [22] in 1969 reviewed the field and defined how a "Health Status Index" could be used to provide "an operational definition of health." A wide-ranging review of the literature on social health indices is that
by Elinson [23], and the abstract of his paper summarizes the position:
"The various forms of mortality data and bio- medical measures of morbidity have become inadequate measures of the level of health in economically
developed countries. Measures of functional physical capacity have some advantages but do not reflect
physical impairment. Current attempts to devedope sociomedical health indicators include: measures of social diability; typologies of presenting symptoms, which have been used to estimate probable needs for care; measures which focus on behavioral expressions of sickness; research based on operational definitions of 'positive mental health', 'happiness' and perceived quality of life- assessments of met and unmet needs for health care, which are measures of social capacity to care for the sick.
Sociomedical indicators reflect both objective conditions and social values. They are policy- oriented, serving as mobilizing agents for socio-
political pressures concerned with raising the overall level of health of the population."
The OECD has since 1970 instituted a program of work on the development of social indicators, and in 1973 published [24] a list of these in which health features prominently: reproduced as Figure 4. This list was used as the basis for work on the second phase of the program, whose objective was "the develop- ment of a set of social indicators to measure the level of well- being for each social concern and to monitor changes in these levels over time." Figure 5 shows the contents of the OECD's comprehensive review [25], published in 1976, which gives details of the problems of definition, and positive proposals for a
coherent series of measures. The World Health Organization has also discussed the problems of planning and objectives in a recent booklet [261
.
F i g u r e 4 S O C I A L INDICATORS
-
L I S T OF S O C I A L CONCERNS CO-WFlON TO MOST MEMBER COUNTRIES ( f r o m OECD, 1 9 7 3 )I GENERAL BACKGROUND INFORMATION
A
FUNDAMENTAL S O C I A L CONCERNS HEALTH
A-1 THE P R O B A B I L I T Y O F A HEALTHY L I F E THROUGH ALL STAGES OF THE L I F E CYCLE A-2 THE IMPACT OF HEALTH
IMPAIRMENT ON I N D I V I D U A L S
I1 REVIEW O F P A S T EFFORTS
SUB-CONCERNS
A-2-a T h e q u a l i t y of h e a l t h c a r e i n t e r m s of r e d u c - i n g p a i n a n d r e s t o r i n g f u n c t i o n a l c a p a b i l i t i e s A-2-b T h e e x t e n t o f u n i v e r s a l d i s t r i b u t i o n i n t h e de- l i v e r y of h e a l t h care A - 2 - c T h e a b i l i t y of t h e
c h r o n i c a l l y i m p a i r e d and p e r m a n e n t l y handicapped t o p a r t i c i p a t e more e f f e c t i v e l y i n s o c i e t y
I11 YONITORING THE LENGTH O F L I F E
I V MONITORING THE HEALTHFULNESS O F L I F E V MONITORING THE QUALITY OF HEALTH CARE V I MONITORING THE DELIVERY O F HEATLH CARE
V I I MONITORING THE INTEGRATION OF THE DISABLED I N S O C I E T Y
F i g u r e 5 CONTENTS O F J A Z A I R I ' S (OECD) PAPER ON "APPROACHES TO THE DEVELOPMENT OF HEALTH INDICATORS"
What these measures (Fanshel and Bush, those reviewed by Elinson, the OECD items in Figures 3 and 4) all have in common is an emphasis on output or outcomes. If the price mechanism is rejected as a criterion, then performance has to be measured in cost-effectiveness terms. Himatsingani, with his DHSS
experiknce, is closely aware of the practical difficulties, and is worth quoting at length [27] :
"Cost-effectiveness analysis demands explicit considerations of attributes which are not measured in money terms. The essential prerequisites of the
approach are briefly as follows:
-
determination of criterion (not economic) against which the care can be measured;-
the need for operationally useful measures of effectiveness which are responsive to the changes in the provision of services;-
assessment of health and social needs, and the factors affecting the conversion of needs into demands."
This specification leads to his emphasizing the need for
research into outcome-based measures, and into the functional relationships between changes in effectiveness and the provision of services. Unit1 this knowledge has been developed, "it will be worthwhile developing a planning framework based on inputs rather than outputs and this framework should be improved and refined as and when more information is acquired". In his conclusions, Himatsingani refers again to the need for better measurement, for research into the concept of need and into health indices, and continues (he was writing just prior to the
1974 reorganization):
"There should be an increased emphasis on planning at central, regional and area levels. One of the areas of research that should be investigated is the develop- ment of a hierarchy of inter-related models, in which progress should be made in making the best use of
available information. Plodels should be made flexible so that these. can be developed further as and when more information is acquired."
This quotation emphasizes the close relationship between what can be operationally usefully established as targets, and the nature of the planning models used; and the consequent need for their flexibility. One might go further, and seek to build adaptive capability not only into the models themselves, but into the structure of the planning systems of which the models form a part. The concept of models integrated in participatively- structured planning activities, incorporating either provisional guesses or established data where available, is well illustrated
i n t h e c a s e r e c e n t l y r e p o r t e d by B u r t o n e t a l . [ 2 8 ] . The
m a t h e m a t i c a l programming a l l o c a t i o n m o d e l s . t o which H i m a t s i n g a n i r e f e r s i n h i s p a p e r h a v e s i n c e b e e n e x t e n s i v e l y d e v e l o p e d w i t h i n t h e DHSS ( e . g . a s d e s c r i b e d by McDonald e t a l . [ 2 9 ] ) , b u t t h e m e a s u r e s a n d o b j e c t i v e s t h e y i n c o r p o r a t e r e m a i n p r i m a r i l y i n p u t - o r i e n t e d , o r a t most i n t e r m e d i a t e o u t p u t s ( c a s e s p e r b e d , e t c . ) . Work a t IIASA ( G i b b s [ 3 0 ] ) h a s u s e d a n o u t p u t - r e l a t e d c o n c e p t o f
" i n f e r r e d u t i l i t y t t . b u t h i s i s a m e a s u r e d e r i v e d ( v i a F e l d s t e i n ' s e l a s t i c i t y c o e f f i c i e n t c a l c u l a t i o n s [ 3 1 ] ) from p a s t c l i n i c a l
b e h a v i o u r
-
t h e d e s c r i p t i v e b e i n g employed a s p r e s c r i p t i v e ( o r m e r e l y p r e d i c t i v e ) .The q u e s t i o n s o f measurement a r e c e n t r a l . They a r e f u r t h e r d i s c u s s e d i n t h e s e c t i o n o n m o n i t o r i n g below, a n d , i n t h e f i n a l s e c t i o n , i n t h e c o n t e x t o f a s p e c i f i c sub-system. Whatever t h e f u t u r e a c h i e v e m e n t s o f r e s e a r c h , t h e c u r r e n t r e q u i r e m e n t t o p r o d u c e p l a n s demands some q u a n t i t a t i v e t a r g e t s ; a n d t h e s e h a v e t o b e a m p l i f i e d t o become p r o g r e s s i v e l y more s p e c i f i c a s o n e moves from c e n t r a l g o v e r n m e n t t o w a r d s t h e o p e r a t i n g u n i t s .
The U n i t e d Kingdom's D e p a r t m e n t o f H e a l t h a n d S o c i a l S e c u r i t y h a s i s s u e d t h e v a r i o u s " g u i d e - l i n e s " a l r e a d y r e f e r r e d t o [ 1 3 , 1 4 ,
151. "The Way Forward" i n c l u d e s m e a s u r e s o f p e r c a p i t a e x p e n d i - t u r e o n e a c h o f 2 6 " s e r v i c e s 1 ' . H i s t o r i c and " i l l u s t r a t i v e p r o j e c - t i o n " f i g u r e s a r e g i v e n f o r t h e s e e x p e n d i t u r e c a t e g o r i e s , a l o n g w i t h s t a f f a n d i n - p a t i e n t bed p r o v i s i o n , a n d f o r t h e l a t t e r ,
m e a s u r e s o f t h r o u g h p u t o r o c c u p a n c y . The s t a t u s o f t h e s e numbers i s n o t t r u l y t h a t o f " t a r g e t s , I 1 s i n c e -WAS h a v e d i s c r e t i o n t o s e t t h e s e f o r t h e m s e l v e s ; b u t t h e y i n d i c a t e some o f t h e q u a n t i t i e s t o which RHAs a r e e x p e c t e d t o g i v e c o n s i d e r a t i o n . In a d d i t i o n , e a c h y e a r ' s b u d g e t a r y a l l o c a t i o n g i v e s t h e r e v e n u e and c a p i t a l a l l o c a t i o n s ; a n d g u i d a n c e i s g i v e n on t h e d i f f e r e n t g r o w t h r a t e s s u g g e s t e d f o r e x p e n d i t u r e - o n t h e d i f f e r e n t s e c t o r s of t h e s e r v i c e .
Many more d e t a i l e d m e a s u r e s o f a c t i v i t y a r e a v a i l a b l e from t h e r o u t i n e l y c o l l e c t e d s t a t i s t i c s o f t h e o p e r a t i n g u n i t s i n t h e h e a l t h a u t h o r i t y . But c a r e m u s t b e e x e r c i s e d i n s e l e c t i n g which m e a s u r e s a r e g i v e n o p e r a t i o n a l o r s t r a t e g i c s i g n i f i c a n c e a s
" t a r g e t s " . A r i s k , t o which n a n y a u t h o r s h a v e drawn a t t e n t i o n , i s t h a t t h e q u a n t i t a t i v e t a r g e t s e l e c t e d t o m e a s u r e p e r f o r m a n c e o n some o b j e c t i v e c a n become s e e n a s more i m p o r t a n t t h a n t h e o b j e c t i v e i t s e l f ; l e a d i n g t o d i s t o r t i o n s , and m i s a l l o c a t i o n o f r e s o u r c e s .
N o t w i t h s t a n d i n g t h e above i n d i c a t i o n s o f i n t e r e s t , t h e need f o r t h e d e v e l o p m e n t o f i n d i c a t o r s i s n o t u n i v e r s a l l y o r w h o l e h e a r t e d l y a c c e p t e d . Again q u o t i n g E l i n s o n [231 :
" D e s p i t e what s e e m o b v i o u s p o l i c y i m p l i c a t i o n s o f h e a l t h i n d i c a t o r s a r e c e n t i n q u i r y among h o s p i t a l admin- i s t r a t d ~ s , p u b l i c h e a l t h p l a n n e r s a n d l e g i s l a t o r s
r e v e a l e d a marked u n c o n c e r n i n s u c h m e a s u r e s . H o s p i t a l a d m i n i s t r a t o r s a p p e a r t o b e q u i t e u n i n t e r e s t e d i n h e a l t h s t a t u s i n d i c a t o r s : t h e o r g a n i z a t i o n a l g o a l s o f h o s p i t a l s are t o p r o v i d e h o s p i t a l s e r v i c e s e f f i c i e n t l y w i t h o u t
r e g a r d t o t h e i r e f f e c t on t h e h e a l t h s t a t u s o f t h e community. A t b e s t , h o s p i t a l a d m i n i s t r a t o r s m i g h t b e c o n c e r n e d w i t h ' c a s e t r e a t e d ' i n d i c a t o r s r a t h e r t h a n w i t h t h e h e a l t h s t a t u s o f p o p u l a t i o n s , g e o g r a p h i c a l l y d e f i n e d . Some h e a l t h p l a n n e r s a r e l o o k i n g f o r a s i n g l e o v e r a l l n a t i o n a l h e a l t h i n d e x , a n a l o g o u s t o t h e Consumer P r i c e I n d e x . L e g i s l a t o r s , a n d o t h e r p o l i c y m a k e r s , o n t h e o t h e r h a n d , show more i n t e r e s t i n t h e e v a l u a t i o n of s p e c i f i c h e a l t h p r o g r a m s t h a n i n i n d i c e s o f t h e h e a l t h o f t h e g e n e r a l p o p u l a t i o n . Who, t h e n , c a r e s a b o u t h e a l t h i n d i c a t o r s ? G l o b a l t h i n k e r s ; t o p p o l i c y m a k e r s , o c c a s i o n a l l y ; m o n o p o l i s t i c t r a d e u n i o n s s u c h a s t h e
American M e d i c a l A s s o c i a t i o n , who when a n a t i o n a l h e a l t h i n d i c a t o r g o e s up o r down f e e l a r e f l e c t i o n on t h e i r s e l f - i m a g e ; a n d s o c i a l r e f o r m e r s who would l i k e t o i n f l u e n c e h e a l t h p o l i c y . "
4 . M O N I T O R I N G AND CONTROL: THE NEED, THE METHODS,
THE SHORTCOMINGS
4 . 1 I n t r o d u c t i o n a n d D i s c u s s i o n o f T e r m s
T h i s s e c t i o n c o n s i d e r s t h e n a t u r e a n d methods o f s t r a t e g i c m o n i t o r i n g and c ~ c t r o l i n p u b l i c s e r v i c e o r g a c i z a t i o n s , p a r t i c - u l a r l y h e a l t h c a r e s y s t e m s . I t i s n o t a c r i t i q u e o f e x i s t i n g o r g a n i z a t i o n s ; t h e e x t e n t o f t h e need i n t h e s p e c i f i c c a s e o f t h e U . K . R e g i o n a l H e a l t h A u t h o r i t i e s i s a m a t t e r f o r c o n t i n u i n g d i s c u s s i o n a n d r e s e a r c h , a n d t h e o b j e c t i v e s o f t h e r e s e a r c h may t h e m s e l v e s b e m o d i f i e d d u r i n g t h e c o u r s e o f d i s c u s s i o n . The c a s e p r e s e n t e d h e r e i s i n g e n e r a l t e r m s , a n d h a s t h r e e p a r t s :
( a ) w h a t i s t h e need f o r , o r p u r p o s e o f , m o n i t o r i n g and c o n t r o l ?
(b) what p u b l i s h e d methods e x i s t , o r a r e viewed a s s t a n d a r d ? ( c ) what s h o r t c o m i n g s h a v e b e e n i d e n t i f i e d i n t h e s e methods?
The e m p h a s i s t h r o u g h o u t t h i s p a p e r i s on " s t r a t e g i c c o n t r o l " ; t h e word " c o n t r o l " c a r r y i n g s u c h c o n n o t a t i o n s a s " r o u t i n e . " and e v e n " a u t o m a t i c " ; b u t w i t h o u t t h e u s u a l l i m i t a t i o n t o " s h o r t - t e r m " . C o n s i d e r , f o r example, t h e f o l l o w i n g q u o t a t i o n from Anthony and H e r k l i n g e r ' s a u t h o r i t a t i v e work [ 3 2 ] , "Management C o n t r o l i n N o n - p r o f i t O r g a n i z a t i o n s " :
"Programming,: I n t h e p r o g r a m i n g p h a s e , d e c i s i o n s a r e made w i t h r e s p e c t t o t h e m a j o r porgrarns i n which t h e o r g a n i z a t i o n i s t o e n g a g e d u r i n g t h e coming p e r i o d . T h e s e d e c i s i o n s e i t h e r a r e made w i t h i n t h e c o n t e x t o f t h e o b j e c t i v e s and s t r a t e g i e s t h a t h a v e p r e v i o u s l y b e e n d e c i d e d upon, o r t h e y r e p r e s e n t c h a n g e s i n s t r a t e g y . I f t h e l a t t e r , t h e y a r e p a r t o f t h e s t r a t e g i c p l a n n i n g p r o c e s s , r a t h e r t h a n t h e management c o n t r o l p r o c e s s ; t h e two p r o c e s s e s merge i n t o o n e a n o t h e r i n t h e programming p h a s e . "
Here t h e r e i s a d i s t i n c t i o n drawn between t h e " s t r a t e g i c p l a n n i n g "
p r o c e s s and t h e "management c o n t r o l " p r o c e s s ; b u t i t i s a t l e a s t a d m i t t e d t h a t t h e i m p l e m e n t a t i o n of major program d e c i s i o n s w i t h i n e s t a b l i s h e d s t r a t e g i c o b j e c t i v e s i s s e e n a s p a r t o f management.
c o n t r o l .
I n t h e American l i t e r a t u r e , much of t h e a p p r a i s a l of s t r a t e g i c programs i s d e s c r i b e d a s " e v a l u a t i o n " . T h i s i s c l o s e t o what w e e n v i s a g e a s s t r a t e g i c c o n t r o l , b u t l a c k s t h e c o n n o t a t i o n o f
r o u t i n e , c o n t i n u i n g a c t i v i t y : s t r a t e g i c c o n t r o l s h o u l d n o t b e s e e n a s a once-off e v a l u a t i o n , s u c h a s H o f s t e d e r e f e r s t o i n t h e q u o t a t i o n i n 4.5 below ( p . 2 7 ) . However, much o f t h e methodology of e v a l u a t i o n
-
e . g . , a s r e v i e w e d and summarized by a u t h o r s s u c h a s C . Weiss [ 3 3 , 3 4 ] and Suchman [ 3 5 ]-
may b e r e l e v a n t t o t h e d e s i g n and o p e r a t i o n o f a s t r a t e g i c c o n t r o l s y s t e m .4.2 The Need f o r M o n i t o r i n g : A D e f i n i t i o n
I f p l a n n i n g i s t o b e more t h a n a paper-producing e x e r c i s e , i t h a s t o b e f o l l o w e d by a c t i o n . The p l a n s a r e n e c e s s a r i l y made on a s s u m p t i o n s and f o r e c a s t s , which a r e u n c e r t a i n . P l a n s a r e made o n l y a t i n t e r v a l s
-
i n t h e case of s t r a t e g i c p l a n n i n g ,p e r h a p s l o n g e r t h a n a y e a r . The adequacy of t h e o r i g i n a l p l a n a s a g u i d e f o r c o n t i n u i n g a c t i o n i s t h e r e f o r e bound t o d e c l i n e w i t h t i m e . M o n i t o r i n g i s t h e p r o c e s s of i n f o r m a t i o n - g a t h e r i n g by
which t h e o r g a n i z a t i o n c h e c k s b o t h i t s performance r e l a t i v e t o t a r g e t s , and t h e b e h a v i o u r o f t h e e n v i r o n m e n t , a s s u m p t i o n s a b o u t which formed p a r t o f t h e b a s i s f o r t h e p l a n and t h e t a r g e t s . C o n t r o l a c t i o n s r e s u l t from t h e m o n i t o r i n g , and a r e t y p i c a l l y :
( a ) t o change c u r r e n t a c t i o n s t o e n s u r e c l o s e r a l i g n m e n t w i t h p l a n ;
( b ) t o r e - i n t e r p r e t p l a n t a r g e t s i n l i g h t of l a t e s t e n v i - r o n m e n t a l i n f o r m a t i o n , and t h e n a s ( a ) above. ( P l a n t a r g e t s a r e o f t e n s e t i n r e l a t i v e
terms,
e . g . , " u n i t s p e r t h o u s a n d p o p u l a t i o n , " s o t h a t a b s o l u t e t e r m s , e . g . ," u n i t s " r e q u i r e a n e n v i r o n m e n t a l i n p u t t o f i x t h e m ) . A t a h i g h e r l e v e l , o t h e r r e s u l t s o f m o n i t o r i n g may be:
( c ) t o d i s c o v e r w h e t h e r a n a s s u m p t i o n made as a b a s i s f o r p l a n n i n g ( e . g . , a p o s t u l a t e d r e l a t i o n s h i p ) h a s i n f a c t proved c o r r e c t ; i f i n f a c t i t i s wrong, o r a more
a c c u r a t e a s s u m p t i o n i s now a v a i l a b l e , a n a d j u s t m e n t t o p l a n may b e made;
( d l t o d i s c o v e r t h a t even t h e p e r f e c t achievement o f a p l a n n e d t a r g e t i s n o t found t o b e s a t i s f a c t o r y , e . g . , b e c a u s e it h a s n o t c o n t r i b u t e d t o w a r d s t h e p o l i c y o b j e c t i v e t o which i t w a s s u p p o s e d l y r e l a t e d . The t a r g e t may t h e n b e abandoned, m o d i f i e d o r r e p l a c e d , and a c t i o n a s i n ( a ) i n i t i a t e d .
The successive, cumulative operation of the above activities might appear tantamount to a continuous planning system. It
differs from planning, however, in its frequency, continuity, and in the fact that there is a steadily growing risk that successive incremental decisions will become increasingly uncoordinated and ultimately incompatible. Moreover, the changes referred to in
(a) to (d) above may be impossible to achieve or implement within the delegated authority or resource constraints at the point where the need for change is identified. Thus the apparently desirable changes, rather than being immediately implemented, have to be accumulated as a list of proposals; to be presented at the next appropriate "decision point". This is both a future point in time and a level in the system, where a more comprehensive view of
implications can be taken; and where there exists the authority to commit the necessary resources.
Every individual is his own decision point, with some dele- gated authority for some scale of resources (even if it is only his own time), and has some view of the implications of his
choices. The system may be viewed as a hierarchy of such decision points, the higher levels characterized by greater authority to alter resource commitments, and lower frequency of operation.
The monitoring system is the process of information collection, organization, interpretation and presentation on which this decision-making hierarchy depends.
On all levels, the results and possible control actions (a) to (d) above have their interpretations. At the strategic level, the necessary actions are the least likely to be capable of
immediate implementation, since they require the widest view of implications and the greatest authority over both resources and policy objectives (item (d) in strategic terms).
Thus the need for a strategic monitoring s y s t e ~ has been defined as twofold: fistly, to stimulate the implementation of control actions; and secondly, where immediate action cannot be implemented, gradually to accumulate the agenda for the next point of strategic review and decision. Since the need for strategic decision may itself be dynamically dependent upon
conditions, rather than fixed by schedule, a further function of strategic monitoring can be to determine occasions when a review of the strategic plan has become necessary.
4.3 Theories and Methods of Control: Introduction
The basic concepts of control have been developed in a number of disciplines, usually labelled by the nature of the system whose control has been attempted or studied. Within the subject of health care, "control" has usually been interpreted primarily as "control of expenditure", and this tendency to view control primarily as a financial function is common throughout industry and government. Money is, after all, the common language of resource allocation; and in industry, is similarly adequate for many purposes as a measure of outputs. In the context of health, however, most national systems prefer to limit or avoid
